Provider Demographics
NPI:1043801087
Name:LEATHAM, MACEY RENAE (RDN)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:RENAE
Last Name:LEATHAM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 IDAHO AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-1247
Mailing Address - Country:US
Mailing Address - Phone:208-716-0244
Mailing Address - Fax:
Practice Address - Street 1:1298 IDAHO AVE APT 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-1247
Practice Address - Country:US
Practice Address - Phone:208-716-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID86096533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered